Solutions). The availability of OTC products and various DIY methods has provided the general population better access to whitening, but use without the supervision of a dentist has raised several potential concerns. Tooth discoloration can be the

secondary effect of an undiagnosed illness, overuse of whitening materials can damage the enamel surface, and the at-home process might go unmonitored (Hammel

(Kwon et al. 2015a). A complete summary, including a comparison of the characteristics of current vital tooth whitening technologies, is listed in Table 1.2. It must be

noted that this presents an overall comparison and may vary based on the specific

material employed.

1.3

Diagnosis and Treatment Planning

If a patient desires whiter teeth or would benefit from tooth whitening in conjunction with restorative or orthodontic treatment, their prognosis depends on the nature

of the discoloration and the expectations of the patient. Discoloration due to extrinsic origins respond better to whitening but even discoloration due to intrinsic origin

(e.g., tetracycline staining) can respond to whitening if the treatment time is sufficient (Haywood 1991). The absolute contraindications to tooth whitening are few,

but unrealistic expectations, an unwillingness to comply with treatment, pregnancy,

allergy to components in the whitening material, and severe sensitivity should be

carefully considered before starting treatment.

1.3.1

Check List During Examination

Like any dental examination, the proper steps for diagnosis include obtaining medical and dental history and radiographs and conducting a thorough clinical

examination.

1

Introduction to Tooth Whitening

11

Active dental caries that may be close to the pulp should be given special attention. Carious lesions can be temporarily treated prior to the whitening treatment and

finalized once the color is stabilized.

A single dark tooth is a red flag and might be associated with a previous traumatic injury or even a periapical pathosis (Kwon 2011). Radiographs and pulp vitality testing can guide the treatment (Chap. 6).

Crack lines are not an absolute contraindication but the patient should be aware

they may exacerbate sensitivity or become even more visible after tooth whitening

(Kwon et al. 2009).

Localized decalcification areas and white spots should be carefully examined as

they might blend in with the lighter tooth color or could become more noticeable

(AlShehri and Kwon 2016). In these instances, other conjunctive treatments such as

microabrasion or resin infiltration and restorative treatment may be indicated

(Chaps. 6, 9, 10, 12, 13, and 15).

Translucent areas often observed on incisal edges will remain translucent upon

whitening treatment and may end up looking grayish, continuing to be a concern for

some patients. In severe cases, a resin composite restoration to mask the translucency may be needed.

Existing tooth-colored restorations in the aesthetic zone should be carefully

examined since there may be a need for retreatment that should be explained in

advance, to allow the patient to make the necessary financial commitment.

The symmetry in gingival contour should be observed and possibly resolved

prior to whitening, in order to enhance the aesthetic outcome.

Severe abrasion, attrition, and recessions should also be observed and explained

to the patient, as root exposures will not respond to whitening (Hilton et al. 2013;

Pashley 1989).

Preexisting tooth sensitivity needs to be addressed prior to the treatment, since it

may become severe upon treatment compromising the outcome of the treatment.

1.3.2

New Challenges in Tooth Whitening

1.3.2.1 Failed Attempts of Tooth Whitening

With the increased interest in tooth whitening, patients currently consult a dental

professional about this technique after several failed attempts of trying it on their

own (Fig. 1.2). Many have used over-the-counter products in various forms with

unsatisfactory results, yet exhibit teeth that are already quite light, making the treatment more challenging. Therefore, it is prudent to establish the expectation of the

patient and discuss the feasibility of reaching this goal. A very realistic and natural

outcome is to reference the white of the eye (Mrazek 2004). However, patients often

want teeth that are even whiter, at which point the dentist should carefully discuss

the patient’s treatment goal, in detail.

1.3.2.2 Erosion

As lifestyles have changed throughout the decades, the consumption of soft drinks

has increased in the United States by 300 % in 20 years (Calvadini et al. 2000; Lussi

12

S.R. Kwon

Fig. 1.2 Patient complained about

previous failed attempts of tooth

whitening. A thorough examination of

existing restorations, recessions,

abfractions, and gingival asymmetry was

followed by a comprehensive treatment

plan to satisfy patient’s desire for an

aesthetic outcome

Fig. 1.3 Generalized

erosion of teeth can

contribute to a more

chromatic appearance of

teeth

et al. 2006). At the same time, the incidence of dental erosion is growing steadily

(Lussi et al. 2006). Initially, erosion is limited to the enamel, but in advanced cases

whiten teeth evenly (Jadad et al. 2011). Nevertheless, more research is needed to

address these special and challenging situations to help clinicians in the decisionmaking process.

14

1.3.3

S.R. Kwon

Monitoring the Progress of Tooth Whitening

The success of tooth whitening is mainly determined by changes in tooth color and

is subjective to each patient; however, evaluating tooth color is extremely difficult

because of the complex optical characteristics of the tooth, which include gloss,

opacity, transparency, translucency, and optical phenomena such as metamerism,

opalescence, and fluorescence (Hunter 1987). Patients commonly inquire about the

expected final shade after tooth whitening. So first recording the baseline tooth

color will help determine the prognosis, and is invaluable in monitoring progress.

The prognosis of whitening is significantly enhanced with shades in the yelloworange range, whereas gray and bluish discolorations are more stubborn (Leonard

2003). Additionally, rather than promising a specific shade, it is prudent to suggest

a reliable reference point, such as the white of an eye, so the patient can perceive the

difference (Mrazek 2004). Commonly the white of the eye is whiter than the baseline tooth color, providing a good reference point for the progress being made during treatment. One of the best ways to demonstrate the efficacy and progress of

whitening is to compare the color difference of the upper, treated arch versus the

lower, untreated arch. This difference is very helpful in encouraging compliance

and also for some who cannot discern color changes well. Many times it is also

important to have color change validated by friends or family, and photographs can

be an essential monitoring tool (Kwon and Li 2013).

The Vitapan Classical (VITA Zahnfabrik, Bad Sackingen, Germany) shade

guide, with values oriented according from the lightest to the darkest tab, is commonly used for visual shade matching. Nevertheless, the lack of logical order, uniform color distribution, and light shade tabs has been pointed out as drawbacks of

the Vitapan Classical (Ontiveros and Paravina 2009). To facilitate the monitoring of

color measurements, can be easily placed along whitened teeth, leading to the anticipation of the whitening progress. The effect of tooth whitening can be easily monitored by selecting the closest shade tab before and after whitening and counting the

difference in tab numbers, expressed as a difference in shade guide units (ΔSGU)

(Kwon et al. 2015b).

Methods using specialized instruments to determine tooth shade have become

available with advancements in technology. These methods have the advantage of

being uninfluenced by the human eye, environment, and light source, and generate